Jan 26, 2018

Called in

The story

You know from countless boring lectures that the length of time involved hits heavier than the dose of information. Does the same hold true for opioid prescriptions?

The epidemic

Depending on where you practice, you may have already learned to write oxy scripts without thinking about it. And that's the problem: there were 240 million opioid prescriptions dispensed in 2015, about one for every adult in the US population. Patients often get more than double the amount of pills that they need following surgery or acute pain. But if the opioid epidemic is rooted in overprescription, there have been few formal guidelines on how to reduce use. Electronic health records will often pre-populate scripts with a 30 - 60 pill supply.

The data

Researchers crunched insurance diagnosis codes for 1 million opioid-naive surgical patients to find which aspects of overprescription lead to addiction. Duration of prescription, rather than dose, was the factor most associated with opioid dependence, abuse, or overdose. Each refill fulfilled after discharge conferred a 44% increased risk of misuse, while every additional week of prescription increased the risk of misuse by 20%. Opioid dose, of key importance in studies of chronic opioid users, was a weak initial predictor of misuse. 

The takeaway

Prescription reform could be a key tool in the fight against opioid abuse. Limiting scripts for acute pain to a few days or a few pills looks like an important first step.

Say it on rounds

When you send your attending a text meant for your significant other

Things that seem routine can quickly get messy. A case series of 364 patients with influenza infection found that they were 6 times more likely to develop an acute myocardial infarction (MI) within 7 days of flu diagnosis than at other times throughout the year. RSV and other viruses were also linked to MI, though less strongly than the flu. Since flu is common and MI is the leading worldwide cause of death, some estimates suggest that the annual flu vaccine may be on par with smoking cessation and statin use as a risk-reducing intervention. A 2-minute video has more.

When there's a strong smell in Room 208, but neither patient seems to notice

There's power in milieu. A look at families living in military bases across the country found that individual BMI correlated with surrounding community obesity rates, even after controlling for shared (potentially unhealthy) environments. Prior studies could not control for self-selection (i.e. similar people living together), but since Uncle Sam controls the location and duration of residence in military family participants, the authors were able to tease out a role for social norms and community in obesity.
JAMA Pediatr

When you're sure that your AKI is worse than your patient's

We feel you. A retrospective analysis found that the fractional excretion of urea (FEUrea) can identify the cause of acute kidney injury (AKI) in cirrhotics. FEUrea was low in type 1 hepatorenal syndrome (median 20%), medium in prerenal azotemia (30%), and high in acute tubular necrosis (44%). Now if only we could get urine collected, we'd have it all figured out.

Brush up

Refractory shock

About 7% of critically ill patients develop refractory shock, an inadequate hemodynamic response to high-dose vasopressors. Short-term mortality exceeds 50%. Avoid getting there by adding vasopressin or epinephrine early in shock cases that do not respond to initial treatment with fluid resuscitation and norepinephrine infusion. When indicated, use adjunctive therapies like sodium bicarbonate, calcium, hydrocortisone, ascorbic acid, and thiamine to reduce pressor requirements.

What's the evidence

For angiotensin II as a second vasopressor in vasodilatory shock? 2017's ATHOS-3 trial randomized 320 patients on medium-dose norepinephrine to treatment with angiotensin II or placebo. Angiotensin II improved mean arterial pressure (MAP) and lowered pressor requirements, but the study was underpowered to detect a difference in mortality.

What your economics friends are talking about

There's a lot of chatter in Davos about the USA's role in international trade. But lost in the hubbub is a new Access to Medicine index that ranks pharmaceutical companies based on their efforts to tackle antimicrobial resistance.

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